directing council regional committee PAN AMERICAN HEALTH ORGANIZATION XXIV Meeting Mexico, D.F. September-October 1976 WORLD HEALTH ORGANIZATION XXVIII Meeting INDEXED Provisional Agenda Item 30 CD24/25 (Eng.) 20 September 1976 ORIGINAL: SPANISH PROPOSAL FOR THE ESTABLISHMENT OF A PAN AMERICAN COMMUNITY HEALTH TRAINING CENTER
FEASIBILITY STUDY ON THE ESTABLISHMENT OF A PAN AMERICAN COMMUNITY HEALTH TRAINING CENTER IN COSTA RICA Costa Rica 13 August to 6 September 1976
Summary This study was conducted pursuant to Resolution VI adopted at the fourth plenary session of the 76th Meeting of the Executive Committee of the Pan American Health Organization. The resolution reflected the proposal for the "establishment of a rural health school with headquarters in Costa Rica," which was submitted by the Government of that country. The study was based on the following concepts: since function is the essential element of a center, all components need not be located at the same place; functions or activities already under way should not be duplicated either wholely or in part; and all institutions in the Region that contribute to the center's goals should be taken into consideration. References cited were the recommendations of the Ten-Year Health Plan for the Americas; the request made to governments that have initiated programs to share their information and experiences with other countries; the cooperation offered by the Government of Costa Rica; the provisions of Resolution VI of the 76th Meeting of the Executive Committee of PAHO; the decisions of the Sixth Meeting of the Directors General of Health of Central America and Panama; analysis and evaluation of Costa Rica's programs to extend health services coverage; and that country's laws governing the health sector. A number of the concepts and expressions used in the resolution and in the Costa Rican Government's proposal were defined to indicate their scope and meaning in this context. An evaluation of the situation was then made to determine available resources for later comparison with the resources required for establishing the center. A thorough analysis was made of the programs for expanding coverage in rural and urban areas and of the functions being performed by personnel in the field and at the various program levels; a number of indicators were used to evaluate those components. Estimated manpower requirements during the decade were determined for each program. (It is noted that the community health program plans to train only 200 community health auxiliaries in 1977; subsequent requirements have not been indicated because training is provided only to fill actual staff vacancies in the health sector.) The training being received by field personnel, both nursing auxiliaries and rural auxiliaries, was reviewed, and the community health auxiliary program, which has been completed, was analyzed. Based on this information, the study sought to determine the educational and pedagogical value of the programs for expanding coverage and the main features they provide to justify their utilization in a center's courses. The following aspects will merely be listed here: existence of an acceptable level of interinstitutional coordination, adjusting a preexisting model;
-2- achievement of total coverage in a relatively short time and at a reasonable cost; a high degree of motivation among all participants, from field personnel to program directors; limitation of training to those tasks that must be carried out in the field. The need for training intermediate and superior administrative personnel in the health sector was considered, based on the deficiencies indicated in the Government's Health Plan, the machinery that is planned or in operation for making the work of such personnel more effective, and the valuable information that will soon be provided by the Central American Public Administration Institute's survey on the public sector of all countries in Central America and Panama. In order to determine the potential teaching personnel available, aside from the Health Ministry staff now providing instruction, two excellent training institutions were visited: the University School of Medicine, and the CCSS Research and Training Center. The courses given by those institutions were listed. It should be recognized that the mere fact that a sufficient number of suitable teachers are available is no guarantee they will want to participate in a center's activities. The study merely indicates the potential manpower. Based on the functions planned for the center, the types and levels of the training and specialization courses offered by other national and regional institutions in Central America and Panama were also analyzed, although not all of the current data needed for this purpose was available. Lastly, the study sought to establish whether the functions proposed by the Government of Costa Rica for the center, that is, dissemination of information, advisory services, and operations research, were now being provided and whether sufficient personnel was available to furnish those services in the future. It was concluded that the Pan American Sanitary Bureau is in the best position to perform the first two functions. For the latter function, the School of Medicine is increasingly strengthening its infrastructure, the Research Department of the CCSS Research and Training Center is of high scientific quality, and community health pilot studies are now about to begin under an agreement with the University of Michigan. In light of the above information and the reference guidelines, options were identified based on the Government's proposal, the resolution, and the need for one or more of the proposed functions to be implemented. The following three options, which may be complementary and of increasing complexity, were identified: 1. A Community Health Training Center; 2. An Information, Advisory and Research Center; 3. A Teachers' Training Center. To determine the need for establishing a Community Health Training Center, a theoretical health care model was constructed for the sole purpose
-3- of identifying levels and functions. The analysis shows that it would be undesirable to train field personnel in a centralized location, because of cost and more particularly for educational reasons; that intermediate personnel now in the system who need to take refresher courses and improve their training should not attend formal courses even in their own country but should take inservice training, and special programs have been designed for this purpose in the case of Costa Rica; for intermediate personnel who are going to enter the health sector, Costa Rica and other countries provide formal courses covering both preliminary and advanced training. Lastly, there is the sector's highest level, which comprises planning, advisory services, and decision-making. It does not appear desirable to establish formal courses at this level for personnel in Costa Rica and other countries who wish to attend a training center. It would be more logical to devise other less formal procedures to provide the same training by means of case studies and theoretical design analysis, because such personnel require wider experience rather than training in basic concepts. With regard to the second option, it is clearly necessary to report and disseminate the experiences of other countries. Those countries must have advisory services available and, of course, there must be machinery and procedures for small scale research to establish the costs and feasibility of introducing larger scale programs. While most of these functions are being performed by the Pan American Sanitary Bureau, centralization that would strengthen the program and provide greater resources to the countries, and the inclusion in this center of highly specialized personnel in such fields as task analysis, systems analysis, data processing and scientific methodology management, would be very useful. Although it is assumed that the teachers' training center should be an essential component of the two options mentioned, if this is rejected, the establishment of a center solely for teacher training should be considered because of the high priority of such training and the increasing requirement for properly trained teachers. The Government proposal offered a number of material resources (building and installations suitable for research, education, administration and project support); financial support (allocations for hiring permanent or temporary staff for support, secretariat, and mobilization services); rural and suburban demonstration areas; and liaison machinery with the university, the CCSS and other national agencies, and the general infrastructure of the Ministry of Health. The source of some resources required must of course be determined once the option has been selected. Educational expenses are involved in the first option (educational equipment; audiovisual and library resources; equipment for reproduction and publication of documents; and transportation and per diem for the personnel to be trained). For the second option, funds will have to be allocated to hire a small group of experts in task analysis, systems analysis, experimental design, planning and overall evaluation.
-4- In making this feasibility study, neither installation nor operating costs could be established, since they will depend on the type of center to be set up. The above analysis, however, gives sufficient information for these costs to be estimated easily once a decision is taken. A comparison between the initial and operating expenses paid by the Ministry of Health and the total requirements of the option selected will indicate the remaining requirements to be covered. To decide on the geographic location of a center, account must be taken of a number of variables that will make possible better utilization of the resources available at the location; taking advantage of the work being performed; what the country is offering for setting up the center and covering its operating expenses; and the means and resources required for effective operation. Costa Rica's offer, which includes initiative, motivation and means, the manpower available in the country, and the success obtained in applying the service coverage models, show that it is the country providing the best conditions for the center. This does not mean that there are no other countries that have equally effective models for expanding coverage or sufficient manpower. The only differences between Costa Rica and the others are the concern indicated by the Government of that country and the means and resources explicitly offered in its presentation. Conclusions 1. The feasibility study attempted by the advisers was confined in scope and depth by the vagueness of the plan for establishing a Pan American Community Health Training Center. This vagueness is due primarily to the lack of the following: 1.1 Selection of the most suitable alternative for the center's ultimate goal. 1.2 Based on the action resulting from that selection, an outline of a center development plan indicating: 1.2.1 participating institutions 1.2.2 available manpower 1.2.3 availability of locations 1.2.4 program of potential achievements 1.3 Political impact of any decision taken. 2. This same lack of definition has also hampered analysis of the need and justification for the center in terms of the type of services it will be able to provide other countries in the Region. 3. Time limitations prevented a comparative analysis of this problem in other countries of the Region, which might provide guidance on the appropriateness of locating the center in Costa Rica and on adjusting the major features of this project to the requirements of other countries.
- 5-4. Despite the difficulties indicated, this study may represent progress insofar as it tries to set forth possible alternatives more clearly. That should facilitate making a final.decision on the option to be chosen and should serve as a basis for later compilation of the data that will be required to complete the feasibility study. 5. Obviously, the indicated factors prevented making the financial study required to complete this feasibility study. Start-up costs and the required resources can be determined when an operational alternative has been defined.